Jessilyn Cauble

NUTR 409
Case Study #18 Renal Disease
1. Describe the physiological functions of the kidneys.
The kidneys play an essential role, such as regulating fluid and minerals in the body.
They also signal the bone marrow to make red blood cells, synthesize vitamin D,
regulate the blood pressure, excrete waste chemicals in the urine and regulate acidbase levels. Individual with kidney diseases will lose these capabilities and have
fluctuation in their levels of calcium and phosphorus.
2. What diseases/conditions can lead to chronic kidney disease (CKD)? Explain the
relationship between diabetes and CKD.
Hypertension can cause CKD because damaged blood vessels can also cause damage
in the kidneys. CKD itself causes blood pressure to rise, compounding the issue and
causing further kidney damage. Other causes of CKD include polycystic kidney disease,
pyelonephritis, glomerulonephritis, occlusion of the renal artery, and long-term use of
NSAIDs and certain antibiotics. The most common cause of CKD is diabetes. This is
due to the high blood glucose levels found in patients with diabetes, the blood vessels
of the kidneys may become damaged, thus reducing the functionality of the kidney over
time if glucose levels of the blood remain chronically high.
3. Outline the stages of CKD, including the distinguished signs and symptoms.
There are five stages of chronic kidney disease. Stage one presents with damage, but
normal / increased function and a eGFR rate of 90-130mL/min (90-120 mL/min is
normal). Stage two presents with a mild decrease in function and 60-89mL/min eGFR.
Stages 1 and 2 are characterized by proteinuria, hematuria, or anatomic issues. Stages
3 and 4 are more advanced with moderate decrease and severe decrease in function,
respectively. Stage 3 has a 30-59mL/min eGFR while stage 4 has 15-29 mL/min.
Finally, stage 5 is considered renal failure or end-stage renal disease and requires
treatment. The eGFR will be less than 15 mL/min. With out dialysis or transplantation
the patient will die.
5. What are the treatment options for stage 5 CKD? Explain the differences between
hemodialysis and peritoneal dialysis.
The treatment options for stage 5 CKD are hemodialysis or peritoneal dialysis.
Hemodialysis binds an artery to a vein via surgery to create a fistula that acts as the
access point for hemodialysis treatment. Before treatment, needles are inserted into the
fistula. The fluid and electrolyte content of dialysate is similar to that of normal plasma.
This allows for diffusion, ultrafiltration, and osmosis of waste products and electrolytes
into the dialysate. Outpatient treatment in a dialysis unit occurs three to five hours three
days a week. Mortality rates have been reduced by implementation of newer therapies,

which shorten the duration of treatment and increase frequency. It is possible for a
patient to receive in-home dialysis, which lasts for two to three and one-half hours for 5
to six days a week. Another option for some patients is nocturnal dialysis that occurs
while sleeping for eight hours three to six times a week.
Peritoneal dialysis (PD) on the other hand uses the peritoneum of the abdominal cavity
and a high dextrose concentrated dialysate is utilized. Waste products diffuse from the
blood, across the peritoneal membrane, and into the dialysate. There is two ways in
which the dialysate is removed. First, continuous ambulatory peritoneal dialysis (CAPD)
is a 24-hour treatment method in which the dialysate is exchanged four to five times
each day manually via gravity. Second is continuous cyclic peritoneal dialysis (CCPD)
where the dialysate is retained in the peritoneum throughout the day and is exchanged
overnight by machine. PD allows the patient to achieve a more normal lifestyle when
compared to hemodialysis. However, some complications of PD include peritonitis or
weight gain. Weight gain stems from the caloric density of the dialysate, which will need
to be addressed with adjustments to overall caloric intake and physical activity.
6. Explain the reasons for the following components of Mrs. Joaquins medical nutrition
therapy:
35 kcal/kg: Energy should be adequate to spare protein for tissue repair and
maintenance protein synthesis and to prevent its metabolism for energy. 35 kcal/kg is
appropriate for Mrs. Joaquin due to her.
1.2 g protein/kg: Dialysis is a drain on body protein, so protein intake must be increased
accordingly. Patients who receive HD 3x per week require daily protein intake of 1.2
g/kg. Due to Mrs. Joaquins progressive kidney failure, she is being prepared for HD
and this recommendation is appropriate.
2 g K: For patients undergoing HD, the recommendation is 2.3 - 3.1 g K per day;
however because Mrs. Joaquin is anuric (having the inability to urinate) the
recommendation is 2 g K per day.
1 g phosphorus: As GFR decreases, phosphorus is retained in the plasma and not
easily removed by dialysis, thus causing patients to experience a net gain of about of
the phosphate they consume daily. For this reason dietary intake of phosphate must be
restricted to 1.2 g/day or less. In Mrs. Joaquins case, phosphate intake is slightly lower
to allow room for phosphate intake from her prescribed high-protein diet. Meats contain
high levels of phosphate in the form of ATP.
2 g Na: Mrs. Joaquin presented with edema in the extremities, face and eyes, which
indicates total body sodium overload. Excessive sodium intake results in increased
thirst, increased fluid gain and subsequent hypertension. Low sodium intake reduces
thirst and prevents large intradialytic fluid gains.
1000 mL fluid + urine output: With patients undergoing HD, sodium and fluid intake must
be regulated to allow for a weight gain of 2 - 3 kg from increased fluid in the vasculature

between dialyses. The goal is a fluid gain or < 4%, and sodium intake of 2 g daily and a
limit on fluid intake of 1000 mL + urine output is usually sufficient to meet these
guidelines.
7. Calculate and interpret Mrs. Joaquins BMI. How does edema affect your
interpretation?
BMI=77.2727/(1.5242) = 33.27 kg/m2 (OBESE: 30.0-34.9 kg/m2)
Edema is the accumulation of fluid in the intercellular tissue spaces or body cavities. It
occurs in pts with CKD due to excess PRO loss in the urine and/or impaired renal
function. In the case of the pt, Mrs. Joaquin, urinalysis shows excessive protein loss (2+
mg/dL, REF. RANGE: Neg). Additionally, her serum creatinine (12.0 mg/dL, REF.
RANGE: 0.6-1.2 mg/dL) and BUN levels (69 mg/dL, REF. RANGE: 8-18 mg/dL) are
both high indicating poor glomerular filtration rate and a high amount of protein
breakdown in the body, respectively. Both are measures of kidney function. The patient
reports a 4 kg weight gain in the past 2 wks, edema in the face and extremities, and
inability to urinate. This retention of fluid likely contributed to a higher body weight, thus
a higher BMI, though still classifying the pt as obese.
BMI before edema=73.2727/(1.5242) = 31.55 kg/m2 (OBESE: 30.0-34.9 kg/m2)
8. What is edema-free weight? Calculate Mrs. Joaquins edema-free weight.
Edema-free weight is body weight without excess fluid buildup, usually calculated after
dialysis. This number is used to assess protein or energy needs for patients that are
less than 95% or more than 115% of the standard weight (NHANES II data).
aBWef = BWef + [(SBW BWef) x 0.25]
= 77.3kg + [(60kg-77.3) x 0.25]
= 73kg
12. What are the considerations for differences in protein requirements among
predialysis, hemodialysis, and peritoneal dialysis patients?
Research has shown that protrein restriction can preserve renal function in mild to
moderate case because protein increases glomerular pressure which can accelerate
loss of renal function. In the case of patients with stage 5 CKD with a glomerular
filtration rate less than 25 milliliters per minute who have not begun dialysis, the
recommendation for protein consumption is 0.6 g/kg a day and 35 kcal.kg a day. If the
patient cannot maintain adequate caloric intake on this protein restriction they can
increase protein intake to 0.75 g/kg per day. In either case at least 50% of the protein
should be from high biologic value sources, which will ensure optimal protein utilization.
Patients on hemodialysis three times a week should consume 1.2 g/kg protein a day.
The increase is due to the depletion of protein stores caused by the dialysis process.
Patients on peritoneal dialysis may experience protein losses up to 30 grams in a 24hour period thus they must receive 1.2-1.5 g/kg protein a day. At least 50% of the

proteins consumed again should be HBV proteins. For most CKD patients it is difficult to
consume adequate protein due to dysgeusia caused by uremia.
13. Mrs. Joaquin has a P04 restriction. Why? What foods have the highest level of
phosphorus?
Mrs. Joaquin is on a P04 restriction because her P04 test came back at 9.5 when the
allowance is 2.3 to 4.7 mg/dL. High level of phosphorus disrupts the balance between
calcium and phosphorus and activates a regulatory hormonal cascade in attempts to reestablish homeostasis. Without healthy kidney tissue, such as Mrs. Joaquin who has
Chronic Kidney Disease, to play a key role in regulating this balance, calcium is then
mobilized from the bone to balance the phosphorus level. As a result, it demineralizes
and weakens healthy bones. The excess calcium and phosphorus from
demineralization cause deposits to form in soft tissue. The deposits harden the soft
tissue causing inflammation and other damaging effects.
Food with the highest level of phosphorus:
Seeds & Nuts, cheese, beer & Cola, dried beans, fish
In Mrs. Joaquin case, her daily consumption of beer, cola, and diary products is the
contributing factor to her elevated phosphorus level.
14. Mrs. Joaquin tells you that one of her friends can drink only certain amounts of
liquids and wants to know if that is the case for her. What foods are considered to be
fluids? What recommendations can you make for Mrs. Joaquin? If a patient must
follow a fluid restriction, what can be done to help reduce his or her thirst?
Yes, that is the case for Mrs. Joaquin because she has been placed on a fluid
restriction. Popsicles, soup, ice cream, cucumber, watermelon, sorbet and gelatin are
examples of foods considered to be fluids in her case. To help reduce Mrs. Joaquins
thirst, the most effective way is to decrease sodium intake. This can be achieved by
eliminating salt in cooking, avoiding salt at the table, avoiding high-sodium convenience
foods, canned soups or canned/cured meats or fish. Mrs. Joaquin should be advised to
quench her thirst via ice chips, having cold sliced fruit, sour candies or using artificial
saliva.
15.Several biochemical indices are used to diagnose chronic kidney disease. One is
glomerular filtration rate (GFR). What does GFR measure? What is a normal GFR? Mrs.
Joaquins GFR is 28 mL/min. Interpret her value.
GFR (glomerular filtration rate) is the amount of blood/waste in milliliters that passes
through the glomeruli per minute. Normal GFR is 90-120 mL/min, whereas the patient,
Mrs. Joaquin, has a low GFR of 28 mL/min. This is considered stage 4 advanced kidney
disease with severe decrease in kidney function.
16. Evaluate Mrs. Joaquins chemistry report. What labs support the diagnosis of
Stage 5 CKD?

The labs that support the diagnosis of Stage 5 CKD are a BUN greater than 100 mg/dL
and a Cr of 10-12 mg/dL which correspond with end-stage renal disease (ESRD). Mrs.
Joaquins Creatnine serum is 12.0 mg/dL, which is ten times the upper limit of the
normal range, is indicative of Stage 5 CKD. Though her BUN is less than 100 mg/dL, at
69 mg/dL it is significantly higher than the normal range of 8 18 mg/dL. Also her
phosphate level is high at 9.5 mg/dL over the normal range of 2.3-4.7 mg/dL. In patients
with renal failure with a decreased GMR, phosphorus is not excreted at the rate it is
consumed due to its large molecular weight.
18. Explain why the following medications were prescribed by completing the following table.

Medication
Capoten / Captopril

Indications/Mechanism
-Used to treat high blood
pressure (hypertension).

Nutritional Concerns
-Salt and Caffiene Intake
conteracting the affect of
the drugs.

-Is an Angiotensin Converting

Enzyme (ACE) that blocks the
body production of angiotensin
II. Angiotensin II is a hormone
that circulates in the blood and
has many effects on the
cardiovascular system; its main
role is to constrict blood vessels.
This constriction can cause high
blood pressure which increase
the work required for the heart to
pump blood into the bodys main
arteries.

Erythropoietin

-Treatment for anemia.

-Erythropoietin, or EPO, is a
naturally occurring glycoprotein
hormone produced in the
kidneys. Specific sensors in the
kidneys monitor the oxygen (O2)
content in the blood. If the
amount of oxygen drops below a
certain level, EPO is released
into the bloodstream. It then
binds to specific EPO receptors
on the surface of cells in the

-Iron depletion in the liver

and need supplementing if
reaches low level.

bone marrow resulting in the

production of more erythrocytes
(red blood cells).
Sodium Bicarbonate

-Is an antacid used to relieve

heartburn and acid indigestion.
-It works by neutralizing excess
acid in the blood.

Renal Caps

-This medicine increases

the amount of sodium in
your body. Sodium/ Salt
intake should be monitored
carefully.

-Use to supplement lost or

depleted B vitamins from the
body especially when going
through dialysis.
-Is a supplement vitamin with
a combination of B vitamins
used to treat or prevent
vitamin deficiency due to poor
diet, certain illnesses,
alcoholism, or during
pregnancy. Vitamins are
important building blocks of
the body and help keep you in
good health. B vitamins
include thiamine, riboflavin,
niacin/niacinamide, vitamin
B6, vitamin B12, folic acid,
and pantothenic acid.

Renvela

-Is used to control phosphorus

levels in people with chronic
kidney disease who are on
dialysis.

-Monitoring of phosphorus
level. Phosphorus free diet.

-Renvela, generically known as

sevelamer is a phosphate binder.
It binds to phosphate preventing
its absorption from the body. It
helps prevent hypocalcemia
caused by elevated phosphorus.

Hectorol

Genericallly known as
Doxercalciferol, it is a synthetic

-Diet restriction on food with

high concentration of

Vitamin D analog that gets

converted to a biologically active
form without the involvement of
the kidney. It is used to treat
people with serious kidney
disease who have high levels of
parathyroid hormone-PTH. High
PTH levels affect the balance of
calcium and phosphorus in the
body and may result in weaken
bones.

vitamin D (such as dairy

and mushrooms) to prevent
overdosage. Overdosaging
may lead to progressive
hypercalcemia, which if
severe, may require
emergency attention.

-High serum phosphorus

may lessen the
effectiveness of Hectorol so
patient should adhere to a
phosphorus restriction diet.
.

Glucophage

Glucophage (metformin) is an
oral diabetes medicine use for
patients with type 2 Diabetes
Mellitus. It helps control blood
sugar by decreasing hepatic
glucose production and
intestinal absorption of
glucose. It improves insulin
sensitivity by increasing
peripheral glucose uptake and
utilization.

-Avoidance of food that will

reduce the blood sugar
content
-Diet must reflect diabetes
needs when it comes to
blood sugar.

19. What health problems have been identified in the Pima Indians through
epidemiological data? Explain what is meant by the thrifty gene theory. Are the Pima at
higher risk for complications of diabetes? Explain.
Epidemiological data reports show that the health problems often identified by Pima
Indians are obesity, gallbladder disease, hypertension, and the worlds highest
prevalence of type II diabetes. The thrifty gene theory attempts to explain why some
populations, such as the Pima are more prone to diabetes. Proposed in 1962 by James
Neel, the thrifty gene theory states that in times of food scarcity, this gene was
beneficial, as it allowed people to gain fat mass quickly during times of food abundance
so as to aid in survival during times of famine. Historically the thrifty gene may have
been advantageous, however during modern times where food is most always
abundant, it has proven harmful to populations prone to inheriting it, such as the Pima
where it can cause obesity and possibly type II diabetes. Because of the

disproportionately high number of Pima Indians who have type II diabetes, and due to
the earlier age of onset observed, the Pima are at a much higher risk of complications
from diabetes such as end stage renal disease, whereas Caucasian diabetes pts are
more likely to die from cardiovascular disease before they develop kidney failure.
Additionally, parents with diabetic nephropathy are at a higher risk for passing on the
genes for diabetes to their children, and thus a higher risk of nephropathy once diabetes
develops in their offspring.
22. Why is it recommended for patients to have at least 50% of the protein from sources
that have a high biological value?
When a protein contains the essential amino acids in a proportion similar to that
required by the body, its considered to have a high biological value. Sources with a
high biological value (HBV) allow for optimal protein utilization. The more amino acids
that need removing the harder the kidneys have to work, which can result in the
acceleration of kidney disease; therefore its important for patients with CKD to have at
least 50% of protein from HBV sources to ensure enough protein to maintain health, but
to minimize the excess amino acids and spare the kidneys.